Membership Guide - Bupasalud
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Membership Guide B U PA GROUP
BUPA GROUP
2ADMINISTRACIÓN
INDEX
AGREEMENT ................................................ 2
BENEFITS.........................................................6
Schedule of benefits ............................... 7
Policy provisions ...................................... 8
EXCLUSIONS AND LIMITATIONS ...... 14
ADMINISTRATION .................................... 16
DEFINITIONS ............................................. 22
SPANISH VERSION.................................... 29
3BUPA GROUP
AGREEMENT
BUPA INSURANCE COMPANY (herein- ELIGIBILITY: This policy can only
after referred to as the “Insurer”) agrees be issued to Employers and their
to pay to the “Certificate Holder”, the Employees residing in Latin America
benefits provided by this policy. All or the Caribbean who work a minimum
benefits are subject to the terms and of thirty hours (30) per week for the
conditions of this policy. Employer. To be eligible for this insur-
TEN (10) DAY RIGHT TO EXAMINE THE ance, the group must have a minimum
POLICY: This policy may be returned of fifteen (15) employees. The Employee
within ten (10) days of receipt for a must have a minimum of eighteen
refund of all premiums paid less an (18) years of age (except for eligible
administrative fee of seventy-five dollars dependents) through a maximum of
($75) and thirty-five dollars ($35) for seventy-three (73) years of age. There
each certificate issued. The policy may is no maximum age for coverage under
be returned to the Insurer or to the the same terms and conditions of this
agent through whom it was purchased. policy for those Insureds renewing a
If returned, the policy is void as though policy. The Employer must contribute at
no policy had been issued. least twenty-five percent (25%) towards
the payment of the premium.
IMPORTANT NOTICE ABOUT THE
APPLICATION: This policy is issued Eligible dependents include the
based on the application and payment Certificate Holder’s spouse, natural
of the premium. If any information born children, legally adopted children,
shown on the application is incorrect or step-children, or children to whom the
incomplete, or any information has been Certificate Holder has been appointed
omitted, the policy may be rescinded, legal guardian by a court of competent
cancelled, or coverage may be modified, jurisdiction, who have been identified on
at the sole discretion of the Insurer. the application and for whom coverage
is provided for under the policy.
2AGREEMENT
Dependent coverage is available for the spouse ceases to be married to the
Certificate Holder’s dependent children Certificate Holder by reason of divorce or
up to their nineteenth (19th) birthday, annulment, coverage for such dependent
if single, or up to their twenty-fourth will terminate on the next anniversary
(24th) birthday, if single and full-time date of the policy.
(minimum twelve (12) credits per Any insured person whose coverage
semester) students of an accredited terminates after three (3) years of
college or university at the time that consecutive and continuous coverage
the policy is issued and renewed. under this policy, and who has never
Coverage for such dependents continues submitted any claim during the lifetime
through the next anniversary date of of his/her coverage under this policy,
the policy, following the attainment and meets other policy requirements,
of nineteen (19) years of age, if single, shall be eligible for an individual Bupa
or twenty-four (24) years of age, Secure Care or Bupa Essential Care
if single and a full-time students. policy offered by the Insurer without
If a dependent child marries, discon- underwriting, with the same conditions
tinues being a full-time student after and/or restrictions in existence under
the nineteenth (19th) birthday, moves this policy.
to another country, or if a dependent
3BUPA GROUP
COMMENCEMENT AND ENDING OF COVERAGE
Coverage begins at 00:01 hours Eastern Standard Time (U.S.A.) on the policy’s
effective date and terminates at 24:00 hours Eastern Standard Time (U.S.A.):
(a) On the expiration date of the policy; (d) Upon written request from the
or Certificate Holder to terminate a
(b) Upon non-payment of the premium; dependent’s coverage; or
or (e) Upon written notification from the
(c) Upon written request from the Insurer, as allowed by the conditions
Certificate Holder to terminate the of this policy.
Certificate Holder's coverage; or
REQUIREMENT TO NOTIFY THE INSURER
The Insured must contact Bupa Insurance Company's Claims Administrator, USA
Medical Services, at least seventy-two (72) hours in advance of receiving any
medical care. Emergency treatment must be notified within forty-eight (48) hours
of commencement of such treatment.
If the Insured fails to contact USA Medical Services as stated herein, the Insured
will be responsible for thirty percent (30%) of all covered medical and hospital
charges related to the claim, in addition to the plan's deductible and coinsurance
(if applicable).
USA Medical Services can be contacted 24 hours a day, 365 days a year at the
following telephone numbers:
In the U.S.A.: (305) 275-1500
Free of charge from the U.S.A.: 1-800-726-1203
Fax: (305) 275-1518
Visit My Bupa in our display options: www.bupasalud.com/MyBupa
Outside the USA: Phone number can be
located on your ID card, or
at www.bupasalud.com
4YOUR HEALTHCARE PARTNER
ONLINE TO MAKE YOUR LIFE EASIER!
Log in to www.bupasalud.com, search for "My Bupa" in our display options and
follow the registration steps with your email to manage your policy from the
comfort of your home or office. Enjoy our online services:
• Access to your policy documents and ID cards
• Payments
• Changes request
• Claim request and update information
• Pre-authorization services request
• Costumer Service
• Virtual Care (Telemedicine)
You are responsible for checking all documents and correspondence online.
5BUPA GROUP
BENEFITS
• See applicable sections of the policy for details, limitations, and restrictions.
• The plan Bupa Group policy provides coverage in the Preferred Provider Network
only. No benefits are payable for service rendered outside the Preferred Provider
Network, except under the emergency medical treatment provision.
• Maximum coverage is five million dollars ($5,000,000) per insured, per lifetime
for all covered medical and hospital charges while the policy is in force, subject
to the limitations herein.
• The insurer, USA Medical Services, and/or any of their applicable related
subsidiaries and affiliates will not engage in any transactions with any parties
or in any countries where otherwise prohibited by the laws in the United States
of America. Please contact USA Medical Services for more information about
this restriction.
6BENEFITS
SCHEDULE OF BENEFITS
Coverage (per Insured, per Policy Year) Maximum benefit
Private or semi-private hospital room and board No limit
Intensive care room and board No limit
Maternity care benefit (Except Plans IV, V and VI)
$2,500
(No deductible or coinsurance applies)
Newborn coverage (No deductible or coinsurance applies) $25,000
Congenital and hereditary disorders:
• Manifested before age 18 $100,000
• Manifested on or after age 18 (per Insured, per lifetime) $5,000,000
Organ transplant (per Insured, per lifetime) $250,000
Air ambulance transportation (per Insured, per lifetime) $25,000
Ground ambulance transportation (per incident) $1,000
Repatriation of mortal remains $5,000
Emergency treatment outside the Preferred Provider
$25,000
Network (per incident)
Disclosed pre-existing conditions (Lifetime maximum,
per Insured after twenty-four (24) months of continuous $25,000
coverage)
DEDUCTIBLE the insured submits claims or requests
for reimbursement for eligible expenses
• All insureds under the Certificate have that occurred during the first nine (9)
a deductible responsibility per policy months of the policy year, the benefit
year according to the plan selected by will be reversed, and the insured will
the Certificate Holder. When applicable, be responsible for the following policy
the corresponding deductible amount year's deductible.
is applied per insured, per policy year
before benefits are paid or reimbursed
to the insured. All deductible amounts COINSURANCE
paid accumulate towards the corre-
sponding maximum deductible per • The Insured is responsible for twenty
Certificate, which is equivalent to the percent (20%) of approved charges for
sum of two individual deductibles. the first five thousand dollars ($5,000)
All insureds under the Certificate after satisfaction of the applicable
contribute to meeting the maximum deductible (except plans IV, V and VI).
deductible amount of the policy. Once • One (1) coinsurance per Insured, per
the maximum deductible amount policy year.
of the Certificate is met, the insurer
will consider all individual deductible
• In the event of an accident involving
multiple members of an Insured family
responsibilities as met. on the same certificate, a maximum of
• Any eligible charges incurred by an two (2) coinsurances will be charged
insured during the last three (3) for this incident. Other coinsurance
months ofthe policy year will apply may be applicable for the members
to that policy year’s deductible and who were not charged coinsurance, for
will also be carried over to be applied other illnesses or injuries not related to
towards that insured’s deductible for the accident.
the following policy year, as long as
there are no expenses incurred during
• If USA Medical Services is notified
in accordance to the policy require-
the first nine (9) months of the policy ments, then coinsurance will not apply
year. If the benefit is granted to carry to medical services in the country of
over the insured's deductible to the residence (except Mexico).
following policy year, and subsequently
7BUPA GROUP
POLICY PROVISIONS
1. ANESTHESIOLOGIST FEES: Cover- 3. HOME HEALTH CARE AND OUT-
age for anesthesiologist fees must PATIENT PHYSICAL THERAPY:
be approved in advance by USA Coverage for this care or treatment
Medical Services and is limited to must be approved in advance by USA
the lesser of: Medical Services, including any and
(a) One hundred percent (100%) all extensions. In all cases, evidence
of the usual, customary and of medical necessity and a treat-
reasonable fee for the anesthe- ment plan must be received by USA
siology charges; or Medical Services.
(b) Thirty percent (30%) of the 4. EMERGENCY DENTAL TREATMENT:
usual, customary and reason- Only emergency dental treatment
able principal surgeon’s fee for that takes place within ninety (90)
the actual surgical procedure; or days of the date of a covered acci-
dent will be covered under this policy.
(c) Thirty percent (30%) of the
fee approved for the principal 5. EMERGENCY MEDICAL TREAT-
surgeon for the surgical proce- MENT: The Plan Bupa Group policy
dure; or provides emergency medical treat-
ment outside of the Preferred Pro-
(d) Special rates established for an vider Network in those cases where
area or country as determined the emergency treatment is required
by the Insurer. to avoid loss of life or limb. Covered
2. ASSISTING PHYSICIAN/SURGEON charges related to an emergency
FEES: Assisting physician/surgeon admission to a non-network pro-
fees are covered only when an vider will be paid up to twenty-five
assisting physician/surgeon is medi- thousand dollars ($25,000) with the
cally necessary for that operation normal plan deductible and coin-
and approved in advance by USA surance (if applicable). The Insured
Medical Services. Assisting physi- will be responsible for thirty percent
cian/surgeon fees are limited to the (30%) of all covered medical and
lesser of: hospital charges that exceed the
(a) Twenty percent (20%) of the benefit of twenty-five thousand
usual, customary and reason- dollars ($25,000) on services per-
able surgeon’s fee for the actual formed outside the Preferred Pro-
surgical procedure; or vider Network.
(b) Twenty percent (20%) of the 6. EMERGENCY TRANSPORTATION:
fee approved for the principal Emergency transportation (by
surgeon for the surgical proce- ground and air ambulance) is only
dure; or covered if related to a covered condi-
tion for which treatment cannot be
(c) If more than one assisting physi-
provided locally and transportation
cian/surgeon is necessary, the
by any other method would result
maximum coverage for all
in loss of life or limb. Emergency
assisting physicians/surgeons
transportation must be provided by a
shall not exceed twenty percent
licensed and authorized transporta-
(20%) of the principal surgeon’s
tion company to the nearest medical
fee for the actual surgical proce-
facility. The vehicle or aircraft used
dure; or
must be staffed by medically trained
(d) Special rates established for an personnel and must be equipped to
area or country as determined handle a medical emergency.
by the Insurer.
8BENEFITS
(a) Air Ambulance Transportation: the effective date of coverage
i. All air ambulance trans- for the respective insured
portation must be pre- mother.
approved and coordinated (d) There is no maternity coverage
by USA Medical Services. for dependent children.
ii. The maximum amount (e) Those Certificate Holders that
payable for this benefit were previously a dependent
is twenty-five thousand child under another policy with
dollars ($25,000) per the Insurer must have main-
insured, per lifetime. tained their own individual
iii. The Insured agrees to hold policy for a minimum of twelve
the Insurer, USA Medical (12) months to be eligible for
Services, and any company this maternity care benefit.
affiliated with the Insurer (f) The twelve (12) month waiting
or USA Medical Services period for maternity coverage
by way of similar owner- always applies regardless of
ship or management, harm- whether or not the ninety (90)
less from any negligence day waiting period for coverage
resulting from such services, under this policy has been
or for delays or restric- waived.
tions on flights caused by There is an optional rider avail-
mechanical problems, by able (except plans IV, V and VI)
governmental restrictions, to cover newborn and maternity
or by the pilot, due to oper- complications.
ational conditions, or from
any negligence resulting 8. NEWBORN COVERAGE:
from such services. (a) If born from a Covered Preg-
(b) Ground Ambulance Transpor- nancy:
tation: The maximum amount i. Provisional coverage: If
payable for this benefit is one born from a covered preg-
thousand dollars ($1,000) per nancy, each newborn will
incident. automatically be covered
7. MATERNITY CARE (Except plans for complications of birth,
IV, V and VI): and any injury or illness for
the first ninety (90) days
(a) There is a maximum benefit after birth up to a maximum
of two thousand five hundred of twenty-five thousand
dollars ($2,500) for each preg- dollars ($25,000) with no
nancy with no deductible or deductible or coinsurance.
coinsurance.
ii. Permanent coverage: For
(b) Pre and post-natal treatment, permanent coverage of a
required vitamins during preg- child born from a covered
nancy, childbirth, complications pregnancy, a “Notification
of pregnancy or delivery, and of Birth” consisting of the
well baby care are included in newborn’s full name, gender
the maximum maternity benefit and date of birth must be
listed in this policy. submitted within ninety
(c) This benefit shall apply for (90) days of birth. Effec-
covered pregnancies. Covered tive as of the date of birth,
pregnancies are those where coverage with applicable
the actual date of delivery is at
least twelve (12) months after
9BUPA GROUP
deductible and coinsurance Certificate effective date,
will then be up to the policy occurring on or after August
limits. 1, 2003;
Policy limits for complica- ii. Twenty five thousand dollars
tions of birth relating to a ($25,000) per person up to
newborn are limited to the the insured’s eighteenth
maximum benefits described (18th) birthday, including
in provision 8 (a) i. any benefits already paid
The premium for the addi- on an existing Certificate or
tion is due at the time of the rider, for insureds born from
notification of birth. If such a covered pregnancy only,
notification is not received when the congenital and
within 90 days of birth, then hereditary disorders initially
an application for insurance manifest themselves prior,
is required on the addition to your policy anniversary
and will be subject to under- date and/or your Certificate
writing. effective date, occurring on
or after August 1, 2003.
iii. Well baby Care: Only covered
as stated in the “Maternity (b) The lifetime maximum benefits
Care” provision of this policy. for any congenital and heredi-
tary disorders that manifest
(b) If NOT born from a Covered themselves on or after the
Pregnancy, there is no provi- insured’s eighteenth (18th)
sional coverage for the newborn. birthday and subsequent, to
To add a newborn to the policy, your policy anniversary date
payment of the premium and and/or your Certificate effective
submission of a completed date, on or after January 1, 2000
application for insurance which are equal to the maximum policy
is subject to underwriting by the limits herein, after deductible
Insurer, are required. and co-insurance (if applicable).
9. CONGENITAL AND HEREDITARY 10. CONTINUOUS GROUP INSUR-
DISORDERS: Coverage under this ANCE COVERAGE (NO GAIN NO
policy for congenital and hereditary LOSS PROVISION): This provision
disorders is as follows: applies to all active groups that had
(a) The lifetime maximum benefits continuous prior group coverage
for any congenital and heredi- with another Insurance Company.
tary disorders that manifest Insureds with disclosed pre-exist-
themselves before the insured’s ing conditions and pregnancies
eighteenth (18th) birthday are: covered under another group plan
i. One hundred thousand will still be covered under this policy;
dollars ($100,000) per however, the policy with the lesser
person, including any benefit will apply for a period of
benefits already paid on twelve (12) months, beginning on
an existing Certificate or the effective date of this policy.
rider, after deductible and After twelve (12) months, the ben-
co-insurance (if appli- efits of this policy will apply. Under
cable), for any congenital this provision the twelve (12) month
and hereditary disorders waiting period for maternity and the
that initially manifest them- two (2) year waiting period for dis-
selves on or after, your policy closed pre-existing conditions will
anniversary date and/or your not be applied. For this provision to
be effective, all employees covered
10BENEFITS
under the previous group plan must after the transplant procedure,
be transferred to this policy. New whether a direct or indirect
employees added to the group policy consequence of the transplant.
after the effective date of this policy (e) Any medication or therapeutic
are NOT subject to this provision. measure used to ensure the
11. ORGAN TRANSPLANTS: Coverage viability and permanence of the
for transplantation of human organs transplanted organ.
and tissues is provided only within (f) Any home health care, nursing
the Insurer’s Organ Transplant Pro- care (e.g. wound care, infusion,
vider Network. There is no cover- assessment, etc.), emergency
age outside the Organ Transplant transportation, medical atten-
Provider Network. The maximum tion, clinic or office visits, trans-
amount payable for this benefit is fusions, supplies, or medications
two hundred fifty thousand dollars related to the transplant.
($250,000) per insured, per lifetime.
This organ transplant benefit begins 12. PREFERRED PROVIDER NETWORK:
once the need for transplantation The Plan Bupa Group policy provides
has been determined by a provider, coverage in the Preferred Provider
has been certified by a second surgi- Network only, regardless of whether
cal or medical opinion and has been the treatment is in your country of
approved by USA Medical Services, residence or outside your country
and is subject to all the terms, pro- of residence. There is no cover-
visions and exclusions of the policy age outside the Preferred Provider
and Certificate. Network, except for emergencies.
This benefit includes: (a) In order to ensure that the
provider of medical services is in
(a) Pre-transplant care, which the Preferred Provider Network,
includes those services directly all treatment, except emergen-
related to evaluation of the need cies, must be coordinated by
for transplantation, evaluation USA Medical Services.
of the Insured for the transplant
procedure, and preparation and (b) In those cases where the
stabilization of the Insured for Preferred Provider Network is
the transplant procedure. not specified in your country of
residence, there is no restriction
(b) Pre-surgical work-up, including on which hospitals may be used
all laboratory and X-ray exams, in your country of residence.
CT scans, Magnetic Resonance
Imaging (MRI’s), ultrasounds, 13. PRESCRIPTION DRUGS: Prescrip-
biopsies, scans, medications and tion drugs are only covered if first
supplies. prescribed during a hospitaliza-
tion or after outpatient surgery
(c) The costs of organ procurement, and for a maximum period of six
transportation, and harvesting (6) months after hospitalization or
up to a maximum of twenty- surgery, unless the Insurer approves
five thousand dollars ($25,000), an extension. In all cases, a copy of
which is included as part of the the prescription from the attending
maximum organ transplant physician must accompany the claim.
benefit.
14. SPECIAL TREATMENTS: Prosthesis,
(d) Post-transplant care including, orthotic devices, durable medical
but not limited to any follow-up, equipment, implants, radiation
medically necessary treatment therapy and highly specialized drugs
resulting from the transplant, (e.g. Interferon, Procrit, Avonex,
and any complications that arise Embrel, etc.) will be covered, but
11BUPA GROUP
must be approved and coordinated Coverage is limited to only those
in advance by USA Medical Services. services and supplies necessary to
Special treatments will be pro- prepare the deceased’s body and
vided by the Insurer or reimbursed to transport the deceased to his
at the cost that the Insurer would country of residence. Arrangements
have incurred if purchased from its must be coordinated in conjunction
providers. with USA Medical Services.
15. PRE-EXISTING CONDITIONS: Pre- 18. REQUIRED SECOND SURGICAL
existing conditions fall into two (2) OPINION: If a surgeon has recom-
categories: mended that an Insured undergo any
(a) Disclosed at the time of appli- non-emergency surgical procedure,
cation: Disclosed pre-existing the Insured must notify USA Medical
conditions unless specifically Services at least seventy-two (72)
excluded by an amendment hours prior to the scheduled pro-
to the policy or Certificate are cedure. If a second surgical opinion
covered after two (2) years from is deemed necessary by either the
the effective date of the certifi- Insurer or USA Medical Services, it
cate, up to a lifetime maximum must be conducted by a physician
lifetime coverage of twenty-five chosen and arranged by USA Medical
thousand ($25,000) per insured. Services. Only those second surgi-
cal opinions required and coordi-
(b) Not disclosed at the time of nated by USA Medical Services are
application: Pre-existing condi- covered. In the event the second
tions not disclosed at the time surgical opinion contradicts or does
of the application will never not confirm the need for surgery, the
be covered during the lifetime Insurer will also pay for a third surgi-
of the policy. Furthermore, cal opinion from a physician chosen
the Insurer retains the right to by USA Medical Services.
rescind, cancel or modify the
policy or Certificate based on If the second or third surgical opin-
the Insured’s failure to disclose ion confirms the need for surgery,
any such conditions. benefits for the surgery will be paid
according to this policy.
16. ILLNESS OR INJURY IN A PRIVATE
AIRCRAFT: Any illness or injury sus- IF THE INSURED DOES NOT OBTAIN
tained as a passenger in a Private A REQUIRED SECOND SURGICAL
Aircraft is covered up to a maximum OPINION , THE INSURED WILL BE
of two hundred and fifty thousand RESPONSIBLE FOR THIRTY PER-
dollars ($250,000) per Insured, per CENT (30%) OF ALL COVERED
lifetime. MEDICAL AND HOSPITAL CHARGES
RELATED TO THE CLAIM IN ADDI-
There is an optional rider available TION TO THE PLAN DEDUCT-
to cover private pilot and crew IBLE AND COINSURANCE. (IF
members. APPLICABLE).
17. REPATRIATION OF MORTAL 19. OUTPATIENT SERVICES: Coverage
REMAINS: In the event an Insured is only provided when medically
dies outside of his/her country of necessary.
residence, the Insurer will pay up
to five thousand dollars ($5,000) 20. MAXIMUM HOSPITAL STAY: The
toward repatriation of the deceased’s maximum hospital stay for any spe-
remains to the deceased’s country cific illness or injury or any related
of residence if the death resulted treatment is one hundred and eighty
from a condition which would have (180) days during the next three
been covered under the terms of hundred and sixty five (365) days
the policy had the Insured survived. after the first admission
12EXCLUSIONS AND LIMITATIONS
21. NOSE AND NASAL SEPTUM DEFOR- 22. TREATMENT AT URGENT CARE
MITY: When nose or nasal septum FACILITIES OR WALK-IN CLINICS:
deformity is induced by a trauma in Treatment at urgent care facilities or
a covered accident, surgical treat- walk-in clinics in the United States of
ment will be covered if authorized America are covered at a hundred
in advance by USA Medical Services. percent (100%) with a fifty-dollar
The evidence of trauma in the form (US$50) co-payment. These treat-
of fracture must be confirmed radio- ments are not subject to deductible.
graphically (X-rays, CT scan, etc.)
13BUPA GROUP
EXCLUSIONS
AND
LIMITATIONS
This policy does not provide coverage or benefits for any of the following:
1. Treatment of any illness, injury, or any 6. Elective or cosmetic surgery or
charges arising from any treatment, medical treatment which is primar-
service or supply which is: ily for beautification, unless neces-
(a) not medically necessary; or sitated by injury, deformity or illness
which first occurs while the Insured
(b) for an Insured who is not under is covered under this policy. This also
the care of a physician, doctor includes any surgical treatment for
or skilled professional; or nasal or septal deformity that was
(c) not authorized or prescribed by not induced by trauma, except as
a physician or doctor; or provided for in this policy.
(d) custodial care. 7. Any charges in connection with pre-
existing conditions, except as defined
2. Any care or treatment, while sane or and addressed in this policy.
insane, received due to self inflicted
illness or injury, suicide, failed suicide, 8. Any treatment, service or supply that
alcohol use or abuse, drug use or is not scientifically or medically rec-
abuse, or the use of illegal sub- ognized for the prescribed treatment
stances or illegal use of controlled or which is considered experimental
substances. This includes any acci- and/or not approved for general use
dent resulting from any of the afore- by the Food and Drug Administration
mentioned criteria. of the U.S.A.
3. Routine eye and ear examinations, 9. Treatment in any governmen-
hearing aids, eye glasses, contact tal facility or any expense if the
lenses, radial keratotomy and/or Insured would be entitled to free
other procedures to correct eye care. Service or treatment for which
refraction disorders. payment would not have to be made
had no insurance coverage existed.
4. Any medical examination or diagnos-
tic study which is a part of a routine 10. Diagnostic procedures or treatment
physical examination, including vac- of mental illnesses and/or psychiat-
cinations and the issuance of medical ric, behavioral or developmental dis-
certificates and examinations as to orders, Chronic Fatigue Syndrome,
the suitability for employment or sleep apnea and any other sleep
travel. disorders.
5. Chiropractic care, homeopathic 11. Any portion of any charge that is in
treatment, acupuncture or any type excess of the usual, customary and
of alternative medicine. reasonable charge for the particular
14EXCLUSIONS AND LIMITATIONS
service or supply for the geographi- illegal activity, including resultant
cal area. imprisonment.
12. Any expense for male or female ster- 23. Acquired Immune Deficiency Syn-
ilization, reversal of sterilization, sex drome (AIDS), HIV positive or AIDS
change, sexual transformation, birth related illnesses.
control, infertility, artificial insemi- 24. An elective admission more than
nation, sexual dysfunction or inad- twenty-three (23) hours before a
equacies and sexually transmittable planned surgery, unless authorized
disease. in writing by the Insurer.
13. Treatment or service for any medical, 25. Treatment of the upper maxilla, the
mental or dental condition related jaw or jaw joint disorders, including
to or arising as a complication to but not limited to jaw anomalies, mal-
those medical, mental or dental ser- formations, temporomandibular joint
vices or other conditions specifically syndrome, craniomandibular disor-
excluded by an amendment to or not ders or other conditions of the jaw
covered by the policy or Certificate. or jaw joint linking the jaw bone and
14. Any expense, service or treatment the skull and complex of muscles,
for obesity, weight control or any nerves and other tissue relating to
form of food supplement (unless that joint.
necessary to sustain life in a criti- 26. Treatment by the spouse, father,
cally ill person). mother, brother, sister or child of
15. Podiatric care to treat functional dis- any insured under a Certificate in
orders of the structures of the feet, this policy.
including but not limited to, corns, 27. “Over the counter” or non-prescrip-
calluses, bunions, Hallux valgus, tion drugs, prescription medications
hammer toe, Morton’s neuroma, flat which are not first prescribed while
feet, weak arches, weak feet or other the Insured is admitted in a hospi-
symptomatic complaints of the feet, tal and prescription medications
including pedicures, special shoes which are not prescribed as part of
and inserts of any type or form. follow-up treatment after outpatient
16. Treatment by a bone growth stim- surgery.
ulator, bone growth stimulation 28. Personal or home based artificial
or treatment relating to growth kidney equipment, unless authorized
hormone, regardless of the reason in writing by the Insurer.
for prescription.
29. Treatment for injury sustained while
17. Treatment for injuries resulting traveling as a pilot or crewmember
from participation in any hazardous in a private aircraft.
activities.
30. Cost relating to the acquisition and
18. All treatment to a mother or to a implantation of artificial heart, mono
newborn related to a non covered or bi-ventricular devices, other artifi-
pregnancy. cial or animal organs and all expenses
19. Any voluntarily induced termina- of any cryopreservation of more than
tion of pregnancy, unless imminent twenty-four (24) hours duration.
maternal demise is apparent. 31. Injury or illness caused by, or related
20. Any congenital or hereditary disor- to ionized radiation, pollution or con-
der or illness, except as provided for tamination, radioactivity from any
under the provisions of this policy. nuclear material, nuclear waste, or
21. Any dental treatment or services the combustion of nuclear fuel or
not related to a covered accident nuclear devices.
or beyond 90 days from the date of 32. Treatment for or arising from any epi-
such accident. demic and/or pandemic disease, and
22. Treatment of injuries resulting while vaccinations, medicines, or preven-
in service as a member of a police tive treatment for or related to any
or military unit or from participation epidemic and/or pandemic disease
in war, riot, civil commotion or any are not covered.
15BUPA GROUP
ADMINISTRATION
1. AUTHORITY: No agent has the 4. OTHER INSURANCE COVERAGE:
authority to change the policy or When another policy is in existence
to waive any of its provisions. After which provides benefits also covered
issue, no change in the policy shall be by this policy, benefits will be coor-
valid unless approved in writing by an dinated. All claims incurred in the
officer or the Chief Underwriter of the country of residence must be made
Insurer and such approval is endorsed in the first instance against the other
by an amendment to the policy. policy. This policy shall only provide
2. CHANGES OF COUNTRY OF RESI- benefits when such other benefits
DENCE: The Insured must notify the payable under the other policy
Insurer in writing of any change of have been exhausted. Outside the
the Insured’s country of residence country of residence, Bupa Insur-
within thirty (30) days of its occur- ance Company will function as the
rence. Changes of residence outside primary Insurer and retains the right
the Insured’s stated country of resi- to collect any payment from local or
dence will, at the Insurer’s discretion, other insurers.
result in modification of coverage or 5. ENTIRE CONTRACT/CONTROLLING
cancellation of the policy or Certifi- CONTRACT: The policy, the Certifi-
cate. Changes of residence to the cate, the application, the Certificate
U.S.A. will result in non-renewal of of Coverage and any riders or amend-
the policy or Certificate. Failure to ments thereto, shall constitute the
notify the Insurer of any change of entire contract between the parties.
the Insured’s country of residence The Spanish translation is provided
may result in cancellation of the policy for the convenience of the Insured.
or modification of coverage on the The English version of this policy will
next anniversary date, at the Insurer’s prevail and is the controlling contract
discretion. THE INSURED’S COUNTRY in the event of any question or dispute
OF RESIDENCE CANNOT BE THE regarding this policy.
UNITED STATES OF AMERICA. 6. GRACE PERIOD: If premium is not
3. COMMENCEMENT OF INSURANCE: received by the due date, the Insurer
Subject to the provisions of this will allow a grace period of thirty
policy, benefits begin on the Effec- (30) days from the due date for the
tive Date of the policy and of each premium to be paid. If the premium
Certificate and not on the date of is not received by the Insurer prior
application for insurance. to the end of the grace period, this
policy and all of its benefits will be
16ADMINISTRATION
deemed terminated as of the original when requested by the Insurer, shall
due date of the premium. Benefits are sign all authorization forms necessary
not provided under the policy during for the Insurer to obtain such medical
the grace period unless the policy is reports and records. Failure to coop-
renewed. erate with the Insurer or failure to
7. INSOLVENCY: The insolvency, bank- authorize the release of all medical
ruptcy, financial impairment, volun- records requested by the Insurer may
tary plan of arrangement with credi- cause a claim to be denied.
tors or dissolution of the Employer’s 12. POLICY CANCELLATION OR NON-
business shall not impose upon the RENEWAL: The Insurer retains the
Insurer any liability other than that right to cancel, modify or rescind the
specifically stated within this policy. policy or a Certificate if statements on
8. PAYMENT OF CLAIMS: It is the Insur- the application are found to be mis-
er’s policy to make payments directly representations, incomplete or that
to physicians and hospitals world- fraud has been committed, leading
wide. When this is not possible, the the Insurer to approve an application
Insurer will reimburse the Certificate when, with the correct or complete
Holder the contractual rate given to information, the Insurer would have
the Insurer by the provider involved issued the policy or Certificate with
and/or in accordance with the usual, restricted coverage or declined to
customary, and reasonable fees for provide insurance.
that geographical area, whichever The Insurer retains the right to cancel
is less. Any charges or portions of or modify a policy or certificate in
charges in excess of these amounts terms of rates, deductibles or ben-
are the responsibility of the Insured. efits, generally and specifically, if the
If a Certificate Holder is not living, the insured changes country of residence,
Insurer will pay any unpaid benefits regardless of how many years the
to the estate of the deceased Certifi- policy has been in force.
cate Holder. If an insured resides in the U.S.A. on
The insurer, USA Medical Services, a continuous basis for more than one
and/or any of their applicable related hundred and eighty (180) days during
subsidiaries and affiliates will not any three hundred and sixty five (365)
engage in any transactions with any day period regardless of the type of
parties or in any countries where oth- visa issued to the insured for that pur-
erwise prohibited by the laws in the pose, the certificate will automatically
United States of America. Please con- terminate on the next renewal date.
tact USA Medical Services for more Submission of a fraudulent claim is
information about this restriction. also grounds for rescission or can-
9. CURRENCY: All currency values cellation of the policy or certificate.
stated in this policy are in U.S. dollars. The Insurer retains the right to cancel,
10. PHYSICAL EXAMINATIONS: The non-renew or modify a policy on a
Insurer, at its own expense, shall have “class” basis as defined in this policy.
the right and opportunity to examine This policy is subject to underwrit-
any Insured whose illness or injury ing evaluation on each anniversary
is the basis of a claim, when and as date, and the insurer retains the right
often as considered necessary by the to cancel or non-renew the policy,
Insurer during the pendency of the modify the coverage, or change the
claim. In the case of death, the Insurer premium.
has the right to request an autopsy
at a facility of its choice. 13. NON-RENEWAL OF GROUP POLICY:
Coverage of this policy can be ter-
11. DUTY TO COOPERATE: The Insured minated either by the Insurer or the
shall make available to the Insurer Employer only on the group policy
all medical reports and records and, anniversary date.
17BUPA GROUP
14. POLICY ISSUANCE: This policy received in currencies other than U.S.
cannot be issued or delivered in Dollars will be in accordance with the
the U.S.A., except as may be spe- official exchange rate, as determined
cifically permitted under the laws by the Insurer, on the date of service.
of the State of Florida. The policy Additionally, the Insurer reserves the
is deemed issued or delivered upon right to issue the payment or reim-
receipt of the policy by the Employer bursement in the currency in which
in its country of residence. the service or treatment was invoiced.
15. POLICY MODE: All policies are 19. REFUNDS: If the Employer, an Insured
deemed annual policies. Premiums or the Insurer cancels the policy or
are to be paid annually, unless the Certificate after it has been issued,
Insurer authorizes other modes of reinstated or renewed, the Insurer
payment. will refund the unearned portion
16. PREMIUM PAYMENT: Payment of the of the premium, less administra-
premium on time is the responsibil- tive charges and policy fees, to a
ity of the Employer. The premium is maximum of sixty-five percent (65%)
due on the renewal date of the policy of the premium. The policy fee, USA
or other due dates if authorized by Medical Services fee and thirty-five
the Insurer. Premium notices are pro- percent (35%) of the base premium
vided as a courtesy and the Insurer are non-refundable. The unearned
provides no guarantee of delivering portion of the premium is based on
premium notices. If an Employer has the number of days corresponding to
not received a premium notice thirty the payment mode, minus the number
(30) days prior to the due date and of days the policy or Certificate was
the Employer does not know the in force.
amount of the premium payment, 20. REINSTATEMENT: All policies or Cer-
the Employer should contact its agent tificates reinstated after the thirty
or the Insurer. Payment may also be (30) day grace period are deemed
made online at www.bupasalud.com. new policies or new certificates with
17. PREMIUM RATE CHANGES: The no antiquity or credit being afforded
Insurer retains the right to change to the Insured. All medical conditions
the premium at the time of each existing prior to the date of reinstate-
renewal date. ment of the policy or Certificate
shall be deemed and treated as pre-
18. PROOF OF CLAIM: Written proof existing conditions under this policy.
of loss must be furnished to USA No reinstatement will be authorized
Medical Services at 17901 Old Cutler ninety (90) days after the date of ter-
Road, Suite 400, Palmetto Bay, mination of the policy or Certificate.
Florida 33157, within one hundred
and eighty (180) days after the treat- 21. CLAIMS APPEALS: In the event of any
ment or service date. Failure to do so disagreement between the Insured
will result in the claim being denied. and the Insurer regarding this Insur-
Original itemized bills must be sub- ance Policy and/or its provisions, the
mitted with the properly completed Insured, before commencing any
Insurer’s claim form and medical arbitration or legal proceedings, shall
records. Standard claim forms from request a review of the matter by the
U.S.A. providers may be accepted, but “Bupa Insurance Company Appeals
the Insurer reserves the right to have Committee”. In order to begin such
the claimant complete the Insurer’s a review, the Insured must submit a
claim form. Claim forms are furnished written request to the Appeals Com-
with the policy or may be obtained by mittee. This request shall include
contacting your agent or USA Medical copies of all relevant information
Services at the address shown herein sought to be considered, as well as an
or through our web site (www.bupas- explanation of what decision should
alud.com). Exchange rates for bills be reviewed and why. Said appeals
18ADMINISTRATION
shall be sent to the attention of the any legal action arising directly or
Bupa Insurance Company Appeals indirectly from this policy. the insurer
Coordinator, c/o USA Medical Ser- and the insured further agree that
vices. Upon the submission of a each party will pay their own attor-
request for review, the Appeals Com- neys’ fees and costs, including those
mittee will determine whether any incurred in arbitration.
further information and/or documen- 23. SUBROGATION AND INDEMNITY:
tation is needed and act to timely The Insurer has a right of subrogation
obtain such. Within thirty (30) days or reimbursement from an Insured to
thereafter, the Appeals Committee whom it has paid any claims to or on
will notify the Insured of its decision behalf of, if such Insured has recov-
and the underlying rationale. ered all or part of such payments from
22. ARBITRATION, LEGAL ACTIONS, a third party. Furthermore, the Insurer
AND JURY WAIVER: Any disagree- has the right to proceed at its own
ment that may persist upon comple- expense in the name of the Insured,
tion of the claims appeal as deter- against third parties who may be
mined herein, must first be submitted responsible for causing a claim under
to arbitration. In such cases, the this policy or who may be responsible
Insured and the Insurer will submit for providing indemnity of benefits for
their difference to three (3) arbiters: any claim under this policy.
Each party selecting an arbiter, and 24. TERMINATION OF COVERAGE
the third arbiter to be selected by the UPON TERMINATION OF POLICY:
arbiters named by the parties herein. In the event a policy or Certificate
In the event of disagreement between terminates for any reason, coverage
the arbiters, the decision will rest with ceases on the effective date of the
the majority. Either the Insured or termination and the Insurer will only
the Insurer may initiate arbitration be responsible for treatment covered
by written notice to the other party under the terms of the policy that
demanding arbitration and naming took place before the effective date
its arbiter. The other party shall have of termination of the policy or Cer-
twenty (20) days after receipt of said tificate. There is no coverage for
notice within which to designate its any treatment that occurs after the
arbiter. The two (2) arbiters named by effective date of the termination,
the parties, within ten (10) days there- regardless of when the condition
after, shall choose the third arbiter first occurred or how much additional
and the arbitration shall be held at treatment may be required.
the place hereinafter set forth ten
(10) days after the appointment of the 25. CHANGE OF PLAN OR DEDUCTIBLE:
third arbiter. If the other party does Through the Employer, at any anniver-
not name its arbiter within twenty sary date, the Certificate Holder can
(20) days, the complaining party may request to change plan or deduct-
designate the second arbiter and the ible. Some requests are subject to
other party shall not be aggrieved underwriting evaluation. The follow-
thereby. Arbitration shall take place ing conditions apply:
in Miami-Dade County, Florida, U.S.A. (a) The benefits earned by seniority
or if approved by the Insurer, in the of the insured will not be
Insured’s country of residence. The affected as long as the new
expenses of the arbitration shall be product or plan contemplates
shared equally between the parties. them. If the previous product
The insured confers exclusive juris- or plan did not include a benefit
diction in miami-dade county, flor- included in the new product or
ida for determination of any rights plan, the specific waiting period
under this policy. the insurer and any established in the Benefits Table
insured covered by this policy hereby of the Policy Cover must be met.
expressly agree to trial by judge in
19BUPA GROUP
(b) During the first ninety (90) days will be limited to the lesser of
from the effective date of the the benefit provided by either
change, benefits payable for the new plan or prior plan.
any illness or injury not caused (e) The benefits with insured
by accident or disease of infec- amounts per lifetime that have
tious origin, will be limited to the already had claims paid under
lesser of benefits provided by the coverage of the previous
the new plan or the prior plan. product or plan, will be reduced
(c) Benefits related to maternity, in the proportion of the expense
maternity complications and already paid. When the total
coverage of the newborn that benefit in the new product or
occur during the ten (10) months plan is less than the amount
following the effective date of already paid under the benefit
the change, will be limited to the in the previous product or
lesser of the benefit provided by plan, the benefit is considered
either the new plan or prior plan. exhausted and coverage under
(d) Benefits with insured sums per the new product or plan will no
lifetime that occur during the longer apply.
six (6) months following the (f) Nevertheless, the insurer reserve
effective date of the change, the right to to carry out standard
underwriting procedures.
20BUPA GROUP
DEFINITIONS
1. ACCIDENT: An unfortunate inci- 6. APPLICANT: The individual who
dent that occurs unexpectedly and executed the application for
suddenly, provoked by an external coverage.
cause, always without the insured's 7. APPLICATION: Written state-
intention, which causes injury or ments on a form by an Appli-
bodily trauma and requires immedi- cant about themself and/or their
ate ambulatory medical attention dependents, used by the Insurer to
and/or patient's hospital admission. determine acceptance or denial of
The medical information related to the risk. Application includes any
the accident will be evaluated by medical history, questionnaire, and
the insurer, and the compensabil- other documents provided to or
ity will be determined under the requested by the Insurer prior to
general policy's provisions. the issuance of the policy.
2. AIR AMBULANCE TRANSPORTA- 8. ASSISTING PHYSICIAN/SURGEON
TION: Emergency air transportation FEES: Charges made by a physician
from the hospital where the Insured or physicians who assist the princi-
is admitted to the nearest suitable pal surgeon in the performance of
hospital where treatment can be a surgical procedure.
provided.
9. CALENDAR YEAR: January 1st
3. AMENDMENT: A document added through December 31st of any
by the Insurer to the policy or Cer- given year.
tificate that clarifies, explains or
modifies the policy or Certificate. 10. CERTIFICATE: The document
issued to the Insured person for
4. ANESTHESIOLOGIST FEES: whom coverage has been approved
Charges made by an anesthesiolo- by the Insurer.
gist for the administration of anes-
thesia during the performance of a 11. CERTIFICATE HOLDER: The named
surgical procedure or for medically Employee in the application for
necessary services for pain control. health insurance. The person enti-
tled to receive reimbursement for
5. ANNIVERSARY DATE: Annual covered medical expenses.
occurrence of the effective date
of the policy. 12. CERTIFICATE OF COVERAGE:
Document of the policy that speci-
fies the commencement, conditions,
22DEFINITIONS
extent and any limitations of the coverage does not mean that they
coverage, and lists each covered do not apply the corresponding risk
person. assessment procedures.
13. CLASS: The Insureds of all policies 18. COUNTRY OF RESIDENCE: The
of the same type, including but not country:
limited to, benefits, deductibles, age (1) where the Insured resides the
group, country, plan, year groups majority of any calendar or
or a combination of any of these. policy year; or
14. COINSURANCE: The portion (2) where the Insured has resided
of the covered medical bills an more than one hundred and
Insured must pay in addition to the eighty (180) continuous days
deductible. during any three hundred and
15. COMPLICATION OF BIRTH: Any sixty five (365) day period while
disorder related to the birth of a the policy is in force.
newborn, not caused by genetic 19. COVERED PREGNANCY: Covered
factors, manifested during the first pregnancies are those where the
thirty-one (31) days of life, including actual date of delivery is at least
but not limited to hyperbilirubine- twelve (12) months after the effec-
mia (jaundice), cerebral hypoxia, tive date of coverage for the respec-
hypoglycemia, prematurity, respira- tive insured mother. Plans IV, V and
tory distress and birth trauma. VI do not have covered pregnancies.
16. CONGENITAL AND HEREDITARY 20. CUSTODIAL CARE: Services pro-
DISORDERS OR ILLNESSES: Any vided that do not require the skills
disorder or illness existing before of a professional and are generally
birth, regardless of its cause, provided on a long term basis, that
whether or not manifested or diag- include but are not limited to room,
nosed at birth, after birth or years board and personal assistance.
later.
21. DEDUCTIBLE: The individual
17. CONTINUITY OF COVERAGE (NO deductible is the amount of covered
LOSS-NON-GAIN): Continuity of charges that must be paid by each
coverage ensures that there is no insured each policy year before
coverage period when changing policy benefits are payable, except
from one product or plan to another when otherwise stated. The family
within the same company or for deducible is the maximum deduct-
transfers between Bupa group ible amount per policy for covered
companies. However, changes charges equivalent to the sum of
and transfers are subject to a non- two individual deductibles per
loss-no-profit provision, whereby policy year.
the least of the benefits payable
between the products or plans 22. DIAGNOSTIC MEDICAL CENTER:
involved in the exchange or transfer Medical facility licensed to perform
are applied during a given period comprehensive medical physical
in advance. The benefits earned by examinations.
seniority of the insured will not be 23. DUE DATE: The date on which the
affected as long as the new product premium is due and payable.
or plan contemplates them. If the 24. EFFECTIVE DATE: The date on
previous product or plan did not which coverage under this policy
contemplate a benefit included in begins and which is stated in the
the new product or plan, the spe- Certificate of Coverage. This date
cific waiting period of that benefit will only be effective after deliv-
established in the Benefits Table ery of the insurance policy to the
must be met. Granting continuity of
23BUPA GROUP
Employer and the expiration of the 32. GROUND AMBULANCE TRANS-
Ten (10) Day Right to Examine the PORTATION: Emergency trans-
Policy. portation to a hospital by ground
25. EMERGENCY: A medical condition ambulance.
manifesting itself by acute signs or 33. HAZARDOUS ACTIVITIES: Any
symptoms which could reasonably activity that exposes the partici-
result in placing the Insured’s life pant to any foreseeable danger or
or physical integrity in immediate risk. Examples of hazardous activi-
danger if medical attention is not ties include but are not limited to:
provided within twenty-four (24) Aviation sports, rafting or canoe-
hours. ing involving white water rapids in
26. EMERGENCY DENTAL TREAT- excess of grade 5, tests of velocity,
MENT: Treatment necessary to scuba diving at a depth of more
restore or replace sound natural than 30 meters, bungee jumping,
teeth, damaged or lost in a covered participation in any extreme sport
accident. or participation in any sport for
compensation or as a professional.
27. EMERGENCY TREATMENT: Medi-
cally necessary treatment due to 34. HOME HEALTH CARE: Care of
an emergency. the Insured in the Insured’s home,
which is prescribed and certified
28. EMPLOYEE: Insured person who
in writing by the Insured’s attend-
has been working a minimum of
ing physician, as required for the
thirty (30) hours per week for the
proper treatment of the illness or
Employer who contracted this
injury, and used in place of inpa-
policy.
tient treatment in a hospital. Home
29. EMPLOYER: The legitimate reg- Health Care includes the services
istered business who contracted of a skilled licensed professional
with the Insurer to provide coverage (nurse, therapist, etc.) outside of
under this policy for its employees, the hospital and does not include
pays the premium, and is entitled Custodial Care.
to receive reimbursement of any
35. HOSPITAL: Any institution which is
unearned premium.
legally licensed as a medical or sur-
30. EPIDEMIC: The occurrence of more gical facility in the country in which
cases than expected of a disease it is located a) which is primarily
or other health condition in a given engaged, in providing diagnostic
area or among a specific group of and therapeutic facilities for clinical
persons during a particular period, and surgical diagnosis, treatment
and declared as such by the World and care of injured and sick persons
Health Organization (WHO), or the by or under the supervision of a
Pan American Health Organization staff of physicians; and b) which is
(PAHO) in Latin America, or the not a place of rest, a place for the
United States Centers for Disease aged or nursing or convalescent
Control and Prevention (CDC), or home or institution or a long term
a local government or equivalent care facility.
body (i.e. local ministry of health)
36. HOSPITAL SERVICES: Medically
where the epidemic is developing.
necessary treatments or ser-
Usually, the cases are presumed
vices ordered by a physician for
to have a common cause or to be
the Insured who is admitted to a
related to one another in some way.
hospital.
31. GRACE PERIOD: The period of time
37. ILLNESS: An abnormal condi-
of thirty (30) days after the policy
tion of the body, manifested by
due date during which the Insurer
signs, symptoms and/or abnormal
will allow the policy to be renewed.
24DEFINITIONS
findings in medical exams, which and physicians in the Organ Trans-
makes this condition different than plant Provider Network is available
the normal state of the body. from USA Medical Services and may
38. INJURY: Damage inflicted to the change at any time without prior
body by an external cause. notice.
39. INSURED: An individual for whom 45. OUTPATIENT SERVICES: Medical
an application has been completed, treatments or services provided
the premium paid, and for whom or ordered by a physician for the
coverage has been approved by the Insured when the Insured is not
Insurer and commenced. The term admitted at a Hospital. Outpatient
“Insured” includes the Certificate services may include services per-
Holder and all dependents covered formed in a hospital or emergency
under this policy. room.
40. LABORATORY AND X-RAY SER- 46. PANDEMIC: An epidemic occurring
VICES: Medically necessary X-ray over a widespread area (multiple
services and laboratory testing countries or continents) and usually
used to diagnose or treat medical affecting a substantial proportion
conditions. of the population.
41. MEDICALLY NECESSARY: A treat- 47. PHYSICIAN OR DOCTOR: A person
ment, service or medical supply who is legally licensed to practice
which is determined by USA medicine in the country where
Medical Services to be necessary treatment is provided and while
and appropriate for the diagno- acting within the scope of their
sis and/or treatment of an illness practice. “Physician” or “Doctor”
or injury. A treatment, service or shall also include a person legally
supply will not be considered medi- licensed to practice as a dentist.
cally necessary if: 48. POLICY YEAR: The period of twelve
(a) It is provided only as a conve- (12) consecutive months beginning
nience to the Insured, the on the effective date of the policy
Insured’s family, or the provider; and any subsequent twelve month
or period thereafter.
(b) It is not appropriate for the 49. PRE-EXISTING CONDITION: A
Insured’s diagnosis or treatment; condition:
or (a) Which was diagnosed by a
(c) It exceeds the level of care which physician prior to the effective
is needed to provide adequate date of the certificate or its rein-
and appropriate diagnosis or statement; or
treatment. (b) For which medical advice or
42. NEWBORN: An infant from the treatment was recommended
moment of birth through the first by or received from a physician
thirty-one (31) days of life. prior to the effective date of the
certificate or its reinstatement;
43. NURSE: An individual legally or
licensed to provide nursing care.
(c) For which any symptom and/or
44. ORGAN TRANSPLANT PROVIDER sign, if presented to a physician
NETWORK: A group of hospitals prior to the effective date of the
and physicians contracted on behalf certificate would have resulted
of the Insurer for the purpose of in the diagnosis of an illness or
providing organ transplant benefits medical condition.
to the Insured. The list of hospitals
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